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| LETTER TO THE EDITOR |
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| Year : 2023 | Volume
: 38
| Issue : 1 | Page : 126-129 |
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Unstable intertrochanteric fracture management by proximal femoral locking plate: Outcome of review studies and its extended role in difficult fracture scenario
Gaurav Govil, Lavindra Tomar, Pawan Dhawan
Department of Orthopaedics, Max Super Specialty Hospital, Patparganj, New Delhi, Delhi, India
| Date of Submission | 16-Jan-2023 |
| Date of Acceptance | 12-Feb-2023 |
| Date of Web Publication | 20-Apr-2023 |
Correspondence Address:
Gaurav Govil
D-101, Sunshine Helios, Sector 78, Noida 201304, Uttar Pradesh
India
 Source of Support: None, Conflict of Interest: None
DOI: 10.4103/jbjd.jbjd_5_23
How to cite this article:
Govil G, Tomar L, Dhawan P. Unstable intertrochanteric fracture management by proximal femoral locking plate: Outcome of review studies and its extended role in difficult fracture scenario. J Bone Joint Dis 2023;38:126-9 |
How to cite this URL:
Govil G, Tomar L, Dhawan P. Unstable intertrochanteric fracture management by proximal femoral locking plate: Outcome of review studies and its extended role in difficult fracture scenario. J Bone Joint Dis [serial online] 2023 [cited 2023 Jun 7];38:126-9. Available from: http://www.jbjd.in/text.asp?2023/38/1/126/374435 |
Dear Editor,
The fixation of unstable intertrochanteric fractures (UITF) has presented unique challenges for surgical fixation. We have a keen interest in understanding the various fixation options for intertrochanteric fracture (ITF) management. We commend the authors for presenting their outlook for suggesting the proximal femoral locking plate (PFLP) as an implant of choice for UITF.[1] The outcomes and complications listed justify their claim in their prospective study.
We feel that there are few relevant observations that need to be discussed to guide decision-making by the clinicians and researchers.
| Outcomes of Biomechanical and Clinical Studies for proximal Femoral Locking Plate in Unstable Intertrochanteric Fractures Management | |  |
We know that the biomechanical studies are preclinical before a clinical trial, aimed to test the mechanical stability of an implant fixation in a certain fracture pattern, and they do not reflect an exact clinical picture.[2] The systematic review (Sys-Rev) revealed no exclusive biomechanical studies for per-trochanteric fractures.[2]
The biomechanical study quoted by authors evaluated the effect of axial loading pattern without cyclical loading on synthetic bone models simulating Arbeitsgemeinschaft für Osteosynthesefragen (AO) 31A2 fractures alone.[3] The intramedullary nailing (IMN) group had a more stable fixation than a PFLP fixation in these unstable fractures. They cautioned clinicians from early weight bearing when fixed with PFLP in comparison to IMN.[3] The study, however, does not comment on the lateral trochanteric wall stability.
The quoted meta-analytical study on randomized controlled trials (RCTs) for UITF fixation with PFLP and dynamic hip sliding screw (DHS) reported similar outcomes for implant-related complications and reoperations.[4] However, it neither provided comparative information on the stress shielding and lateral migration of fracture fragments nor it emphasized on the prevention of collapse and change in neck-shaft angle during fracture healing for both the implants.
The other prior biomechanical studies have also focused on subtrochanteric fractures in isolation with a comparative evaluation of locked plates with minimally inserted plates and blade plate fixation.[5],[6],[7] The PFLP plates were reported to have a lower failure load than IMN and were superior to angle blade plates.[2],[7]
The early results with PFLP fixation had high failure rates due to loss of reduction.[8],[9] PFLP fixation also presented with high failure rates and reoperations in AO A3 UITF.[10] The literature lacks studies detailing a long-term outlook with PFLP. The clinical studies have suggested that proper choice of implant for UITF may depend on various contributory factors especially age, fracture geometry, and coexistent osteoporosis.
| Outcomes of Systematic Reviews for proximal femoral locking plate in Unstable Intertrochanteric Fractures Management | | |
The Sys-Rev for treating A3 ITF involving nine RCTs concluded that IMN and DHS have comparable fracture healing complication rates. They had unjustified the use of fixed plates for treating UITF.[11] A Sys-Rev with network metanalysis on ITF, which included 61 RCTs with 25 internal fixation methods, had no exclusive comment and observation for PFLP fixation probably due to lack of sufficient data.[12] They concluded the highest complication rates with proximal femoral nail (PFN) than a DHS, and suggested proximal femoral nail anti-rotation (PFNA) use in elderly fracture.[12]
Marmor et al.[13] identified the importance of uniform reporting for quality of reduction by radiological metrics specifically lateral wall integrity, neck-shaft angle restoration along with length and femoral neck rotation assessment. The tip apex distance has been the most important factor for predicting screw cutout, although it becomes redundant with the use of PFLP. Hence, no logical comparative evaluation for risk of cutout or failure can be done between an IMN/DHS or PFLP fixation.
Cheng and Sheng[14] performed a Sys-Rev with network metanalysis with 36 RCTs on eight methods of fixation for ITF to evaluate their efficacy and safety; however, their review did not even consider PFLP as a routinely used fixation method for UITF. They considered PFNA as an optimal treatment method. Another Sys-Rev of seven RCTs has identified the highest hip scores in long term with PFN as compared with DHS or bipolar hemiarthroplasty (BHA). However, reoperation rates and failures were reported to be lower with BHA.[15]
We observe that neither the Sys-Rev nor metanalysis have shown the superiority of any intramedullary or extramedullary fixation device for UITF fixation in relevance to the aspects of UITF healing, complications, and reoperations. An ideal choice of implant remains elusive.
| Extended Use of Proximal Femoral Locking Plate in Unstable Intertrochanteric Fractures | | |
We also wish to highlight the extended role of PFLP in grossly UITF with a subtrochanteric extension not amenable to IMN fixation.[16] To illustrate, we present the radiology of a case including three-dimensional computed tomography scan images [Figure 1] and [Figure 2], where the static locking provided stable fixation with PFLP and allowed sound union and good functional outcome [Figure 3]. The prerequisites were proper reduction, restored anatomy and adequate spanning of fracture for fixation. | Figure 1: Preoperative radiograph of right hip in anteroposterior view (A) and oblique view (B) showing unstable intertrochanteric fracture with subtrochanteric extension
Click here to view |
 | Figure 2: Preoperative 3D computerized tomographic scan of right proximal femur with anteroposterior (A), lateral (B), and posterior (C) view delineating the fracture geometry
Click here to view |
 | Figure 3: Postoperative radiograph of right hip with proximal femoral locking plate fixation and cerclage wiring in anteroposterior (A) and lateral (B) view
Click here to view |
The revision osteosynthesis with PFLP in failed UITF fixation was another scenario, which allowed reasonable outcomes with sound union in young patients with salvageable femoral head.[17]
| Conclusion | | |
We appreciate the authors’ work and believe that the clinical studies will provide the evidence for the clinicians to base their decisions in UITF management. The aforementioned concerns merit further discussion. The clinical studies will strengthen the evidence and further RCT-based Sys-Rev may clarify the choice of implant for UITF management.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
Ethics approval
Not considered for a letter to the editor with a retrospective case report as per policy.
Authors’ contributions
GG contributed to the study conception, design, investigation, and methodology. GG performed the literature search and prepared the first draft of the manuscript. GG and LT performed data collection and interpretation. LT and PD did a review analysis. All authors commented on the previous versions of the manuscript. All authors read and approved the final version of the manuscript.
Consent for publication
The patient was informed that data from the case would be submitted for publication and the patient gave the consent.
| References | | |
| 1. | Singh CK, Deshpande J, Shah A, Agarwal P Can PFLP be the implant of choice for unstable trochanteric fractures? Outcomes and complications. J Bone Joint Dis 2022;37:39-49.  [Full text] |
| 2. | Viberg B, Rasmussen KMV, Overgaard S, Rogmark C Poor relation between biomechanical and clinical studies for the proximal femoral locking compression plate. Acta Orthop 2017;88:427-33. |
| 3. | Ozkan K, Türkmen I, Sahin A, Yildiz Y, Erturk S, Soylemez MS A biomechanical comparison of proximal femoral nails and locking proximal anatomic femoral plates in femoral fracture fixation: A study on synthetic bones. Indian J Orthop 2015;49:347-51. |
| 4. | Zhang L, Shen J, Yu S, Huang Q, Xie Z Percutaneous compression plate versus dynamic hip screw for treatment of intertrochanteric hip fractures: A meta-analysis of five randomized controlled trials. Sci World J 2014;2014:512512. |
| 5. | Crist BD, Khalafi A, Hazelwood SJ, Lee MA A biomechanical comparison of locked plate fixation with percutaneous insertion capability versus the angled blade plate in a subtrochanteric fracture gap model. J Orthop Trauma 2009;23:622-7. |
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| 7. | Kim JW, Oh CW, Byun YS, Oh JK, Kim HJ, Min WK, et al. A biomechanical analysis of locking plate fixation with minimally invasive plate osteosynthesis in a subtrochanteric fracture model. J Trauma 2011;70:E19-23. |
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| 9. | Streubel PN, Moustoukas MJ, Obremskey WT Mechanical failure after locking plate fixation of unstable intertrochanteric femur fractures. J Orthop Trauma 2013;27:22-8. |
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| 11. | Parker M, Raval P, Gjertsen JE Nail or plate fixation for A3 trochanteric hip fractures: A systematic review of randomised controlled trials. Injury 2018;49:1319-23. |
| 12. | Qi G, Chen K, Yan Z, Yuan H Internal Fixation Treatments for Intertrochanteric Fracture: A Systematic Review and Network Meta-Analysis. Available from: https://ssrn.com/abstract=3727307 or doi: 10.2139/ssrn.3727307. [Last accessed on 12 Jan 2023]. |
| 13. | Marmor M, Guenthner G, Rezaei A, Saam M, Matityahu A Reporting on quality of reduction and fixation of intertrochanteric fractures: A systematic review. Injury 2021;52:324-9. |
| 14. | Cheng YX, Sheng X Optimal surgical methods to treat intertrochanteric fracture: A Bayesian network meta-analysis based on 36 randomized controlled trials. J Orthop Surg Res 2020;15:402. |
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[Figure 1], [Figure 2], [Figure 3]
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